Benefits

• UVa Health Plans
  • Authorization to Disclose Protected Health Information (PDF)
  • Authorization to Disclose Protected Health Information to Family Member or Other Person (PDF)
  • COBRA 2011 Eligibility and Enrollment for UVa Health Plan and Davis Vision (PDF)
  • COBRA 2012 Eligibility and Enrollment for UVa health Plan and Davis Vision (PDF)
  • Catalyst Mail Order Form (EXTERNAL)
  • Catalyst Prior Authorization (EXTERNAL)
  • Catalyst Rx Reimbursement Form (EXTERNAL)
  • Dental Claim Form (PDF)
  • Housestaff Medical Enrollment Form (PDF)
  • Aetna Medical Claim Form (PDF)
  • Southern Health Medical Claim Form (PDF)
  • Mid-Year Qualifying Event Affidavit (PDF)
  • Foreign Country Enrollment Form (PDF)
  • UVa Health Plan Enrollment Form Medical Center Employees (PDF)
  • UVa Health Plan Enrollment Academic Employees
  • Postdoc and Research Associate Medical Enrollment Form (PDF)
  • Medicare Part D Notice (PDF)
• Vision Insurance
  • Davis Vision Plan Enrollment Form (PDF)
  • Davis Vision Claim Form (PDF)
• Flexible Spending Accounts
  • FSA Claim Form (PDF)
  • FSA Status Change Form (PDF)
• Life and AD&D Insurance
  • Housestaff - Guardian Life Insurance Enrollment Form (PDF)
  • Medical Center - Prudential Life Insurance Enrollment Form (PDF)
  • Medical Center - Prudential Life Insurance Beneficiary Designation (PDF)
  • Medical Center - Prudential Life Insurance Evidence of Insurability - Long Form (PDF)
  • Medical Center Accidental Death and Dismemberment Beneficiary form (PDF)
  • VRS - Minnesota Life Optional Life Enrollment Form (EXTERNAL)
  • VRS - Minnesota Life Optional Life Change Form (EXTERNAL)
  • VRS - Minnesota Life Beneficiary Change Form (EXTERNAL)
  • VRS - Minnesota Life Evidence of Insurability (EXTERNAL)
  • VRS - Minnesota Life Conversion Form (EXTERNAL)
  • The Standard Life Enrollment/Change (PDF)
  • The Standard Medical Statement (PDF)
  • The Standard Conversion Form (PDF)
  • CIGNA AD&D Insurance Application (PDF)
  • CIGNA AD&D Beneficiary Form (PDF)
• Medical Leave
  • Family Medical Leave (FMLA) Form (PDF)
• VRS Forms
  • VRS Forms Web Page (EXTERNAL)
• ORP, MCRP, TDSP and Cash Match
  • TDSP Authorization (Academic) (EXTERNAL)
  • TDSP Authorization (Med Center) (EXTERNAL)
  • 457 Enrollment Form (PDF)
  • 457 Payroll Change Form (PDF)
  • Fidelity Enrollment, Fund and Performance Information
  • Fidelity 401a Beneficiary form (PDF)
  • Fidelity 401a/403b Combination Beneficiary Form (PDF)
  • TIAA-CREF Enrollment, Fund and Performance Information
• Medex Forms
  • Medex Travel Assistance Enrollment (PDF)